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David K. Wallace, MD, MPH

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In reply

The authors emphasize that treatment arms had different dosages and therapist contact times because their study was designed as an effectiveness trial to compare treatments as they are used in clinical practice. I understand this reasoning, but if I am going to recommend to my patients a more expensive and time-consuming treatment as first-line therapy, I want to be confident that there is something about the therapy itself (aside from its dosage or other variables) that sets it apart from less expensive home-based options. My uncertainty about the superiority of office-based treatment persists because office-based and home-based groups differed in at least 3 important ways: the mode of treatment received, the duration of treatment received, and the amount of therapist contact time.¹ Therefore, we cannot know the relative contribution of each of these factors to the reported improvement in symptom survey scores.

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